Government of Canada
Symbol of the Government of Canada

Executive Summary

This report represents the culmination of the work undertaken by the Independent Listeriosis Investigative Review, which was set up to examine the factors that contributed to the 2008 listeriosis outbreak. This tragic event resulted in serious illness for 57 vulnerable individuals and eventually cost the lives of 221 Canadians.

The Independent Investigator was appointed in January 2009 to explore how and why the outbreak happened, and to make recommendations about what can be done to prevent a similar incident in the future. This work has been driven by a determination to find answers to these questions for surviving family and friends, and others directly affected by the event. To understand the process that led to this report, please see the introduction which describes the steps taken in this review and how best to read the full report. The work of this Investigation has been complemented by the important work of the House of Commons Agriculture Subcommittee on Food Safety which has also examined many aspects of this critical matter.

"In all likelihood, none of the individual elements that contributed to the outbreak was sufficient to have caused it alone, so each part of the food safety system must work together as perfectly as possible."

Dr. John Carsley
Medical Health Officer for the Vancouver Coastal Health Authority in British Columbia
Member of the Listeriosis Investigation Expert Advisory Group

This report describes the chain of events which led to the recall of 191 meat products produced by Maple Leaf Foods Bartor Road plant. The report assesses how well federal organizations and their food safety partners responded to the event. It notes best practices from other jurisdictions which have been incorporated into the recommendations.

Most importantly, the report focuses on areas which require urgent attention, providing recommendations for concrete action. The Investigation calls on governments and industry to take swift and appropriate steps to make sure a tragedy such as this doesn't happen again.

Since these main points, like the complete report, must answer the questions of a wide variety of audiences - from scientists and health professionals, to journalists and Parliamentarians (and government officials), to food industry workers and family members - they highlight our key findings and refer to key recommendations of interest to all Canadians. To guide readers, bracketed numbers correspond to the recommendations found in the section entitled 'List of all recommendations' as well as embedded throughout the full report.

Why it matters

Foodborne illness outbreaks like that of 2008 do not happen often in Canada. There has, however, been a steady increase in listeriosis cases in recent years. Since 2005, the number of cases of listeriosis reported annually in Canada has doubled. Among those at greatest risk of contracting the illness are older people - one of the fastest growing segments of Canada's population. Some 40% of those who became ill during the 2008 listeriosis outbreak died of the disease. The average age of people who had listeriosis listed as the underlying or contributing cause of death was 76.

Equally noteworthy, almost 80% of those who developed listeriosis lived in a long term care home or were admitted to a hospital that had served contaminated deli-meats from large packages produced specifically for institutions.

The risks of foodborne illness are also greater than ever before. Large scale farming and food processing, along with the impacts of globalization which provide consumers with access to foods from around the world, all contribute to increased opportunities for contamination. These same trends make it harder to trace the source of a foodborne illness than in the past, when outbreaks were usually linked to local food sources.

A complex disease

Listeriosis, itself, can be hard to detect. The first symptoms of the illness appear between three to 70 days after contaminated food is eaten and, even then, are initially difficult to distinguish from the flu. It is often only when people become seriously ill that lab tests are conducted; a positive result confirming that an individual has the disease. Unlike TV dramas, in which scientific testing produces nearly instantaneous results, it takes several days before bacteria DNA fingerprints results are available.

The greater challenge is connecting the illness to the consumption of a specific food, a process which can take several weeks. Multiple tests are needed, often involving specialized labs, which may require inter-governmental cooperation. Not all communities can do the necessary testing to confirm that listeriosis is what is making people ill and, if so, the particular food they ate that was contaminated. Rapid testing, analyses and reporting of test results are critical to public health and food safety investigators in a national foodborne emergency in order to identify the exact illness and the food source causing it. In light of the growing frequency of foodborne illnesses, this is equally crucial to all Canadians.

By Symptom Onset Date or Estimated Date

By Symptom Onset Date or Estimated Date

How Canada's food safety system works

A foodborne emergency is complex because of the multiple sectors involved and the way Canada's health and food safety systems work. There are many different steps and people involved at each stage in the food supply chain, including consumers themselves.

Overseeing the activities of all these groups are three levels of government, each with varying responsibilities for public health and food safety. Federal, provincial and territorial governments and local entities administer their respective laws and regulations, using their own systems and procedures.

Responsibility for food safety within the federal government is shared among Health Canada, the Canadian Food Inspection Agency (CFIA) and the Public Health Agency of Canada (PHAC). Similar functions are also performed at the provincial, and sometimes, local levels which demands close working relationships and clear lines of authority and communication in a foodborne emergency.

Because coordinating the response to large national outbreaks of foodborne disease is unusually complex, the federal, provincial and territorial governments have a joint protocol, the Foodborne Illness Outbreak Response Protocol, which identifies their individual roles and responsibilities in investigating and overseeing a national health emergency. It was put in place as a result of a previous national foodborne emergency.

How events unfolded

With the benefit of hindsight, we have been able to understand the day-by-day, step-by-step actions taken as the emergency unfolded. An abbreviated chronology, found in Chapter 6, "How did events actually unfold", as well as a fully detailed one, available in Appendix B, have been prepared to guide readers.

Key dates of the outbreak

February to July (2008) - sporadic positive Listeria test results at Bartor Road plant

June 3 - earliest known human illness linked to the listeriosis outbreak

June 17 - first death linked to listeriosis from contaminated Maple Leaf Foods product

July 10 - first 2 listeriosis cases in the outbreak identified through DNA fingerprinting

July 18 - Maple Leaf Foods first identified as possible source of contaminated food products

July 22 - 11 food samples from Toronto long-term care home sent for testing

July 29 - more than double the normal number of listeriosis cases (24 vs. 11 expected) reported by almost half of Ontario public health units

August 4 - food samples from long-term care home test positive for Listeria monocytogenes

August 7 - THE CFIA initiates a food safety investigation

August 12 - DNA fingerprinting matches cases from several provinces

August 13 - Maple Leaf Foods advises distributors to hold certain products

August 16 - THE CFIA confirms Listeria monocytogenes in Maple Leaf Foods products (Sure Slice)

What the Investigation Found

In retrospect, it is easy to see the mix of variables that created the conditions enabling listeriosis to take hold (Chapter 5). Listeria defeated the best efforts of all those trying to prevent it from entering the food supply, including workers attempting to control it in the Maple Leaf Foods Bartor Road plant. It also evaded the oversight systems of both Maple Leaf Foods and the federal government (CFIA). As a result, a segment of the population that is the most vulnerable was exposed to its damaging and sometimes deadly effects.

Once people were ill, there were many challenges in managing the emergency right in the middle of summer. It brought together multiple jurisdictions and two sectors of the federal government that, on a day-to-day basis are not required to work closely together: the public health and food safety sectors. When viewed through the lens of public health, the focus is primarily on identifying what is making people ill. But when viewed through the lens of the food safety sector, the focus is primarily on identifying the exact food product that is causing the illness so that the correct food is removed from the market. This, coupled with the infrequent occurrence of such emergencies, compounded the challenges in managing this event (Chapters 7 and 8).

After in-depth analysis, and expert advice from five food safety and public health authorities, the Investigation found weaknesses in four critical parts of the food safety system which are summarized below. Our analysis has also identified additional improvements, which can be found throughout the various recommendations.

  1. The focus on food safety among senior management in both the public and private domains.

Our key findings are:

Maple Leaf Foods

  • Maple Leaf Foods' Bartor Road plant was aware that it had occurrences of Listeria in the plant in 2007 and 2008, and tried to correct the problem with sanitation procedures standard in the industry. The plant's management thought Listeria was under control. (Chap. 5, Rec. 5, 15 a to d)
  • Maple Leaf Foods did not conduct the trend analysis required under its Listeria control policy. The recurring positive results were not known nor were the positive results verified to determine the presence/absence of Listeria monocytogenes. At the same time, the company was producing larger packages of deli-meat products for sale to institutions, including hospitals and long-term care homes. They had created a recipe that used less sodium, which was attractive to the institutional market as many of its clients benefited from reduced-sodium diets. This combination of circumstances exposed vulnerable populations to risk. (Chap. 5, Rec. 15 e, 21)
  • Maple Leaf Foods staff notified their superiors of the repeated presence of Listeria beyond the Bartor Road plant into the Head Office. However, this information did not reach the office of the Chief Executive Officer because it was thought that the plant's interventions had controlled the problem. (Chap. 5, Rec. 1)
  • Employees in the Maple Leaf Foods Bartor Road plant were not required to, nor did they volunteer, information concerning the repeated occurrences of Listeria in the plant to the CFIA Inspectors. (Chap. 5, Rec. 6)

Canadian Food Inspection Agency

  • A new federal inspection approach, the Compliance Verification System (CVS), was put into effect in the spring of 2008, at the same time Maple Leaf Foods' environmental testing was identifying Listeria at the Bartor Road plant. (Chap.5, Rec. 10)
  • Although the CVS is regarded as a sound system and has broad support, it needs critical improvements related to its design, planning, and implementation. (Chap.5, Rec. 10)
  • The CFIA inspectors had no obligation to request or examine the company's Listeria testing results under their CVS tasks. (Chap.5, Rec. 20)
  • In the lead-up to the outbreak the number, capacity and training of inspectors assigned to Maple Leaf Foods Bartor Road plant appear to have been stressed due to their responsibilities at other plants, the complexity of the Bartor Road plant including its size and hours of operation, and necessary adjustments required by the implementation of the CVS. (Chap.5, Rec. 7)
  • Due to the lack of detailed information and differing views heard, the Investigation was not able to determine the current level of resources as well as the resources needed to conduct the CVS activities effectively. For the same reason, we were also unable to come to a conclusion concerning the adequacy of the program design, implementation plan, training and supervision of inspectors, as well as oversight and performance monitoring. (Chap.5, Rec. 7)
  • The latest CFIA Listeria controls do not distinguish between foods at much lower risk of harbouring Listeria (e.g. dried sausages) and those that are much higher risk (e.g. hot-dogs). Furthermore, they do not establish 'test and hold' product controls. (Chap.5, Rec. 15 d)
  • There is a need for increased coordination and improved communication about food processing equipment among the manufacturer, the food processor, and the CFIA regarding design specifications and the validation of sanitation procedures. (Chap.5, Rec. 14)

Health Canada

  • The Health Canada Listeria monocytogenes policy (currently under review) does not provide adequate direction on expected outcomes leaving room for interpretation by industry. The lack of integration with the CFIA policies creates gaps and overlaps. (Chap.5, Rec. 11)
  • In approving food additives and technologies, Health Canada has not been taking into account food safety considerations when assigning priorities or fast-tracking for approval these substances and processes. (Chap.5, Rec. 12)

Multi-jurisdictional Emergency Response

  • National foodborne outbreaks are rare in Canada. Nevertheless, the Foodborne Illness Outbreak Response Protocol (FIORP) and complementary agreements are in place to manage such events but they were not widely known or understood by senior leadership at the time of the 2008 outbreak. (Chap.5, Rec. 24)
  1. The state of readiness of the various governments.

Our key findings are:

Multi-jurisdictional Emergency Response

  • The 2008 outbreak first emerged in Ontario and was therefore under provincial leadership.
  • At the outset, the outbreak was not considered a severe foodborne emergency. This led to a void in leadership in managing the crisis. It took close to three weeks before senior executives in all key organizations became fully engaged in the event. (Chap. 7, Rec. 24 b.i)
  • The protocol (FIORP), which is in need of updating, was not recognized as the protocol to be used. The lack of a clear understanding about which organization or level of government was responsible for doing what - including which organization should lead the response to the crisis - contributed to the inconsistent management of the outbreak. Few of those involved in the 2008 outbreak, especially senior executives, were familiar with the FIORP. (Chap. 7, Rec. 24)
  • Since national foodborne illness outbreaks of this magnitude are rare in Canada, opportunities to practice this emergency management approach are very limited. (Chap. 7, Rec. 24 c)
  • Public health labs are not formally networked and could be more effectively used during a foodborne illness emergency. (Chap. 7, Rec. 33)
  • The Public Health Agency of Canada is making headway in epidemiological data collection and analysis in cases of human illness (e.g. H1N1), but improvements are still required in integrating the data collection, and analysis, of food samples (e.g. listeriosis). (Chap. 7, Rec. 35 c)
  • Enhanced coordination of various testing (e.g. cross-coding of human and food samples linked to the same patient) could further accelerate the analysis and decision-making necessary in the management of foodborne emergencies. (Chap. 7, Rec. 35 a)
  • Based on our investigation, to maintain confidence in the food safety system, there is a need for independent review after all national foodborne emergencies, in addition to each organization's lessons learned review. (Chap. 7, rec. 27)
  • Most organizations involved in the response to the 2008 outbreak had very limited pre-planned surge capacity. (Chap. 7, Rec. 24 b-iii and 34 b)
  1. The sense of urgency at the outset of the outbreak.

Our key findings are:

Maple Leaf Foods

  • Maple Leaf Foods did not initially report the presence of Listeria at the Bartor Road plant or provide product distribution records. (Chap. 5, Rec. 6)

Public Health Agency of Canada

  • The Public Health Agency of Canada did not consider it had the federal leadership role, therefore there was a delay in identifying the outbreak as a public health emergency. (Chap. 7, Rec. 24 b-i)

Health Canada

  • Health Canada's Health Risk Assessment team was not operating on a 24/7 basis during the summer of 2008, leaving gaps in coverage during the response to the emergency. (Chap. 9, Appendix C)

Public Health and Food Safety Sectors

  • There are differing views on the quality of evidence needed to advise the public about potential food contamination and/or to recall the food product. Some advocate specific laboratory confirmation to ensure the correct product is removed from the market. Others advocate for a precautionary approach, based on epidemiological evidence, to protect the public from potential harm. (Chap. 7, Rec. 24 b-iv, 29)
  1. National communications with the public

Our key findings are:

  • Canadians were seeking reassurance from governments that public health was being protected.
  • Information about the outbreak did not provide the public with what they needed; it was sometimes inconsistent given the many jurisdictions involved, sometimes hard to find and sometimes difficult to understand. (Chap. 8, Rec. 26, 40)
  • The majority of Canadians were unaware which segments of the population were at greater risk of becoming ill if exposed to Listeria monocytogenes, and what foods these vulnerable groups should avoid (e.g. pointing to the need for precautionary labelling). (Chap. 8, Rec. 42)
  • There was an absence of an 'advance' communications strategy and related implementation plan, that should have included ready-made information products and the use of traditional and new media vehicles. (Chap. 8, Rec. 41)
  • Federal communications to the public were slow off the mark, and were not sustained for a sufficient period of time. In addition, there was no designated communications coordinator, which resulted in a fragmented approach and seemingly inconsistent messaging. (Chap. 8, Rec. 37)
  • Having the Minister responsible for Agriculture and Agri-food and the CFIA serve as the lead ministerial spokesperson, was considered by some to be a 'conflict of interest' even though the minister has a legitimate role in relation to the food industry. It appeared to limit government's capacity to communicate health information sought by the public. The perceived lack of federal public health leadership during the outbreak attracted many comments. (Chap. 8)
  • The greatest challenges for physicians in educating patients about minimizing risks of foodborne illness are lack of patient-friendly materials (77%), lack of knowledge about the outbreak (69%), and lack of time (69%). (Chap. 8)

What else was learned

The Investigation came across other matters of capacity, governance and structure affecting the response to the outbreak and meriting further examination. Progress has been made since the 2008 outbreak on a number of fronts however, there is room for ongoing improvement in the federal food safety and legislative framework. Readers are strongly encouraged to review Chapter 10 (Rec. 43, 44, 52) to gain a better understanding of the additional recommendations.

Actions, not words

Many of the issues - and even some of the recommendations generated by this Investigation - have been raised in previous reports on food safety in Canada. Recommendations are only words on paper until they are acted on.

As foodborne illnesses are now the largest class of emerging infectious diseases in the country, and listeriosis is a serious disease with deadly consequences for vulnerable groups, governments cannot afford to ignore these findings.

That is why the Investigation recommends that, in setting its agenda for the fall of 2009, the Government of Canada should be mindful that food safety requires increased attention. Although Canada is viewed as a leader in food safety practices and systems, the Government should clearly and emphatically commit to the safety of food as one of its top priorities. (Chap. 10, Rec. 56)

Everyone involved in the events leading to, and in managing the response to, the 2008 listeriosis outbreak should view the lessons learned from this tragic event and the recommendations as imposing an obligation to pursue innovation and improvement.

The Independent Investigator invites all to read the full report.

1The number of cases reported changed over time as results were confirmed, a process that took time.